Weekly Journal

Plank of Wood

He is as stiff as a plank of wood in the chair he sits in, and his voice is whispery ethereal. The wife responds when the doctor asks whether they are present to confirm a previous diagnosis. She nods enthusiastically and takes off on an explanation of their experience with a previous neurologist who put the patient on ropinirole. The physician nods and comments what he would really like to know is what the patient experienced as the first symptom that worried him and thought he should seek a doctor. The patient responds in a breathy whisper, he noticed weakness in his left side and felt he was dragging his left foot. His idea was confirmed when he detected the heel of his left sneaker had worn considerably more than the right. Then his voice changed. People on the phone have a hard time comprehending his words. The specialist admits he can see from the lack of adventitious movements, the patient suffers from a parkinsonian syndrome. He comments most people typically move about spontaneously, adjusting their legs, moving their hands and face, blinking and moving their glasses or repositioning themselves in the chair. People with Parkinson’s disease lose all these extraneous actions.
The doctor explains Parkinson’s disease may be divided into those that suffer predominantly from a rigid- akinetic form, and those whose illness is tremor- dominant. Those who partition the illness into such categories have found the rigid- akinetic form of disease typically carries a worse prognosis than the tremor dominant form, with a more aggressive course of disability and more dementia. Although the disease affects the dopamine- rich cells of the basal ganglia, causing them to die off in great numbers, the illness also affects other neurotransmitters. Noradrenalin, involved in the function of bowel, bladder and temperature regulation, also becomes depleted and patients usually are beset with problems of urinary frequency, constipation and episodes of feeling intensely hot and cold. Such problems however, are usually not part of the scenario so early in the course of illness.
When the patient has become comfortable on the examination table, the physician begins the physical exam beginning with an assessment of the patient’s eye movements. Though range of motion is full, the muscles that move the eyes show ratchet- like jerky motion, when the patient follows the pen in the physician’s hand. The good news is he is able to gaze fully upwards and downwards. There is marked cogging in the muscles of the left arm, with the left side showing more impairment than the right, and the physician comments this is what one might expect in Parkinson’s disease. The dexterity and the amplitude of movements of the left hand are also more affected than the right, though when resting his hands in his lap, there is only the finest of tremors in the left hand. The physician finds the reflexes in the patient’s legs are brisk, and spread to the other side of the body. He checks the reflexes of the arm; they are brisk as well. He comments brisk reflexes indicate the long, cortical spinal tracks, which course down the spinal cord, have lost their inhibition, in the cortex. He checks the reflex of the jaw, which is intact and normal, and speculates the patient may have some osteo- degenerative changes that are impinging on the long nerves in his spine, at the level of his neck.
The doctor draws out a chart, which illustrates the manner in which he is to add a half- tablet, every three days to the daily dosage of Sinemet. He notes the chart is a stairway in which the patient will go up, until he eventually arrives upon a dose where he feels good, and his movements are full. If he feels light- headed on a dose, he may elect to hold at that level, or even back off a stair, to a lower dose. He gives the patient and wife the chart, prescriptions for Sinemet, Seroquel for sleep and physical therapy and remarks he would like to see them back again in six months, to see how things have developed.

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